Tissue repair suture plates and methods of use

ABSTRACT

Tissue repair suture plates and methods of use are provided which can, in general, allow soft tissue to be secured to bone. In one embodiment, a tissue repair suture plate can include a plurality of openings formed therethrough that can each be configured to have one or more sutures passed therethrough. Each of the sutures can be configured to be coupled to a soft tissue to be positioned against bone for healing thereagainst such that the soft tissue can have multiple sutures coupled thereto at different areas thereof. One or more bone fixation elements can be coupled to the plate and can be configured to attach the plate to the bone. The plate can be configured to move between a first configuration in which the plate has a first maximum length and a second configuration in which the plate has a second, greater maximum length.

FIELD OF THE INVENTION

This application is a divisional of U.S. patent application Ser. No.13/537,670 filed on Jun. 29, 2012, entitled “Tissue Repair Suture Platesand Methods of Use,” which is hereby incorporated by reference in itsentirety.

BACKGROUND OF THE INVENTION

The complete or partial detachment of ligaments, tendons and/or othersoft tissues from their associated bones within the body are relativelycommonplace injuries, particularly among athletes. Such injuries aregenerally the result of excessive stresses being placed on thesetissues. By way of example, tissue detachment may occur as the result ofan accident such as a fall, over-exertion during a work-relatedactivity, during the course of an athletic event, or in any one of manyother situations and/or activities. In the case of a partial detachment,the injury will frequently heal itself, if given sufficient time and ifcare is taken not to expose the injury to further undue stress. In thecase of complete detachment, however, surgery may be needed to re-attachthe soft tissue to its associated bone or bones.

Numerous devices are currently available to re-attach soft tissue tobone. Examples of such currently-available devices include screws,staples, suture anchors and tacks. In soft tissue re-attachmentprocedures utilizing screws, the detached soft tissue is typically movedback into its original position over the bone. Then the screw is screwedthrough the soft tissue and into the bone, with the shank and head ofthe screw holding the soft tissue to the bone. Similarly, in soft tissuere-attachment procedures utilizing staples, the detached soft tissue istypically moved back into its original position over the bone. Then thestaple is driven through the soft tissue and into the bone, with thelegs and bridge of the staple holding the soft tissue to the bone. Insoft tissue re-attachment procedures utilizing suture anchors, ananchor-receiving hole is generally first drilled in the bone at thedesired point of tissue re-attachment. Then a suture anchor is deployedin the hole with a portion of one or more sutures secured to the anchor,with the free end(s) of the suture extending out of the bone. The freeends of the suture are passed through or around the soft tissue and areused to tie the soft tissue securely to the bone.

With any of the above techniques, it is generally desirable to increasethe number of fixation points where tissue is secured to bone in orderto increase the surface area of the tissue drawn into contact with thebone, which can facilitate healing, and to decrease the load on thetissue at any one point, which can help prevent tissue damage. In thecase of soft tissue reattachment with suture anchors, one approach toincreasing the number of fixation points is to increase the number ofsuture anchors. Too many suture anchors, however, can compromise theintegrity of the bone due to the amount of bone material that must beimpinged and/or removed to install the suture anchors. Another approachto increasing the number of tissue fixation points that does not requirean increase in the number of suture anchors is to attach multiple suturestrands to each anchor. However, the multiple suture strands extendingfrom an anchor must generally be passed through the same region oftissue because if tissue too remote from the anchor is drawn towards theanchor, the tissue may pucker or fold. Because the multiple suturestrands are passed through the same region of tissue, the load on thetissue is not appreciably reduced.

Accordingly, there remains a need for improved methods and devices forattaching tissue to bone.

SUMMARY OF THE INVENTION

The present invention generally provides tissue repair suture plates andmethods of use. In one aspect, a surgical method is provided thatincludes affixing an elongate plate to bone in proximity to detachedsoft tissue using one or more bone fixation elements coupled to theplate and extending into the bone, the plate having a plurality ofopenings, and a plurality of suture strands extending from the platealong a length thereof. Each of the plurality of openings has at leastone of the plurality of suture strands extending therethrough. Themethod also includes passing the suture strands through portions of thedetached soft tissue and drawing the detached soft tissue into contactwith the plate and the bone, and securing the soft tissue with thesuture strands at a desired position in contact with the plate and thebone.

The elongate plate can be formed from any one or more materials, such asby being formed from at least one of a flexible mesh, a bioabsorbablematerial, and an osteoconductive material.

The method can have any number of variations. For example, the softtissue can be secured to the plate and bone by at least one of knottingand tying one or more of the suture strands. For another example, one ormore of the suture strands can be secured to the one or more bonefixation elements. In yet another example, the suture strands can beattached to and extend from the elongate plate before affixing theelongate plate to bone, and/or after delivering the elongate plate intoa body of a patient including the bone to which the elongate plate isaffixed. In another example, the elongate plate can be delivered into abody of a patient to a tissue reattachment site in a deliveryconfiguration in which the plate is folded, and prior to affixing theelongate plate, the plate can be unfolded and oriented in asubstantially linear configuration such that a bone contacting surfaceformed along a length of one surface of the plate is substantially incontact with the bone.

In another aspect, a surgical plate is provided that includes anelongate plate member having bone fixation elements coupled to opposedends of the plate, at least one hinge region formed between the anchors,the hinge region extending across a width of the plate, and a pluralityof openings formed through the plate member and extending from a bonecontacting surface thereof to a soft tissue seating surface thereof.

The surgical plate can have a number of variations. For example, theopenings can include a plurality of slots formed along a length of theelongate plate member. For another example, one or more suture strandscan be slidably disposed within the slots. For yet another example, aplurality of strands of suture can extend from the elongate plate memberand be configured to secure soft tissue to the tissue seating surface ofthe elongate plate member. The strands of suture can be secured throughone or more of the openings, each strand of suture having a portionabutting a land region of the elongate plate member located betweenadjacent openings, having a first suture limb extending from a first oneof the adjacent openings, and a having second suture limb extending froma second one of the adjacent openings. For yet another variation, theelongate plate member can have an intermediate portion between theopposed ends, and the width of the plate at the opposed ends can begreater than the width of the plate at the intermediate portion. Thesurgical plate can also include bone fixation elements configured to beseated in bores formed in the opposed ends of the plate so as to couplethe bone fixation elements to the bone, the bone fixation elements beingconfigured to be fixated to bone. The bone fixation elements can includeone or more of a suture, a suture bushing, and an anchor. In anotherexample, the bone fixation elements can be integrally formed with theplate.

The elongate plate member can also be formed from a variety ofmaterials. For example, the elongate plate member can be bioabsorbableand can be made from a material selected from the group consisting ofpoly-L-lactide (PLLA), poly(lactic-co-glycolic acid) (PLGA),poly-L/D-lactide (PLDLA), polyglyconate, polylactic acid (PLA),polyglycolic acid (PGA), polycaprolactone (PCL), polydioxanone (PDO),and trimethylene carbonate (TMC). For yet another example, the elongateplate member can be osteoconductive and can be at least one of made fromand coated with a material selected from the group consisting ofbiphasic calcium phosphate, hydroxyapatite, α-tricalcium phosphate,β-tricalcium phosphate, bioactive glass, calcium phosphate, calciumsulfate, calcium carbonate, xenogeneic and allogeneic bone material.

In another aspect, a soft tissue anchoring system is provided thatincludes one or more anchors having a head and at least one boneengaging surface feature on a shank thereof, an elongate plate memberhaving one or more bores formed therein for receiving the one or moreanchors, and a plurality of openings extending therethrough, and aplurality of suture strands extending from the plate member.

BRIEF DESCRIPTION OF THE DRAWINGS

The invention will be more fully understood from the following detaileddescription taken in conjunction with the accompanying drawings, inwhich:

FIG. 1 is a top view of one embodiment of a tissue repair suture platein an expanded configuration;

FIG. 2 is a side, cross-sectional view of the plate of FIG. 1;

FIG. 3 is a side, cross-sectional view of the plate of FIG. 1 with aplurality of sutures coupled thereto and having a plurality of anchorspositioned near openings formed through the plate;

FIG. 4 is a side, cross-sectional view of the plate of FIG. 3 with theanchors seated in the anchor seating openings;

FIG. 5 is a top view of another embodiment of a tissue repair sutureplate in an expanded configuration;

FIG. 6 is a side, cross-sectional view of another embodiment of a tissuerepair suture plate in an expanded configuration;

FIG. 7 is a side, cross-sectional view of another embodiment of a tissuerepair suture plate in an expanded configuration and having anchorsintegrally formed therewith;

FIG. 8 is a perspective view of an embodiment of a delivery devicecoupled to an embodiment of an anchor disposed within an anchor seatingopening formed through the plate of FIG. 5, which is in a foldedconfiguration, the plate and the anchor being positioned adjacent abone;

FIG. 9 is a perspective view of the plate, the anchor, and the bone ofFIG. 8 with the anchor advanced into the bone, the delivery devicehaving been removed from the anchor;

FIG. 10 is a perspective view of the delivery device of FIG. 8 and theplate, the anchor, and the bone surface of FIG. 9 with the deliverydevice coupled to another anchor positioned adjacent the plate;

FIG. 11 is a perspective view of a tissue attached to the bone of FIG.10; and

FIG. 12 is a side view of another embodiment of a delivery device, thedelivery device being coupled to another embodiment of an anchordisposed within an anchor seating opening formed through anotherembodiment of a tissue repair suture plate.

DETAILED DESCRIPTION OF THE INVENTION

Certain exemplary embodiments will now be described to provide anoverall understanding of the principles of the structure, function,manufacture, and use of the devices and methods disclosed herein. One ormore examples of these embodiments are illustrated in the accompanyingdrawings. Those skilled in the art will understand that the devices andmethods specifically described herein and illustrated in theaccompanying drawings are non-limiting exemplary embodiments and thatthe scope of the present invention is defined solely by the claims. Thefeatures illustrated or described in connection with one exemplaryembodiment may be combined with the features of other embodiments. Suchmodifications and variations are intended to be included within thescope of the present invention.

Various exemplary tissue repair suture plates, and methods of use areprovided. In general, the tissue repair suture plates, also referred toherein as plates, and tissue repair suture plate systems can allow forattaching tissue to bone, such as in repair of torn rotator cuffs. Theplates can allow at least one suture to be coupled to a tissue to besecured to bone without requiring the at least one suture to be securedto an element, e.g., a suture anchor, inserted into the bone, which canhelp prevent weakening, damaging, and/or otherwise adversely affectingthe bone. In one embodiment, a plate can include a plurality of openingsformed therethrough that can each be configured to have one or moresutures passed therethrough such that a plurality of sutures can becoupled to the plate. Each of the plurality of sutures can be configuredto be coupled to a soft tissue, e.g., passed therethrough, to bepositioned against bone for healing thereagainst such that the softtissue can have multiple sutures coupled thereto at different areas ofthe soft tissue. Each of the plurality of sutures can be tensioned tooptimize contact of the soft tissue with bone. The plate's openings cantherefore allow multiple sutures to be coupled to the soft tissuewithout requiring the sutures to be coupled to elements inserted intobone, e.g., suture anchors, which can help reduce damage to the bone.Because the sutures can be coupled to the soft tissue at differentpoints, and can therefore be tensioned at different points of the softtissue, a load can be more evenly distributed across the soft tissuethroughout healing than with sutures all passed through a same point oftissue. Such load balancing can help facilitate contact of the softtissue with bone and/or can help reduce chances of any of the suturescutting through (e.g., cheese wiring through) the soft tissue.Additionally, one or more bone fixation elements, e.g., a suture anchor,a suture bushing or eyelet, a suture line-lock, etc., can be coupled tothe plate, such as by being integrally formed therewith or by beinginserted through one or more bores formed through the plate. The one ormore bone fixation elements can be configured to attach the plate tobone, thereby helping to hold the plate, the sutures, and the tissue ina substantially fixed position relative to the bone, which canfacilitate healing. The one or more bone fixation elements can each haveone or more sutures coupled thereto. Each of these sutures can becoupled to the soft tissue coupled to the sutures passed through theopenings and can be tensioned similar to that discussed above, therebyfurther improving load balancing. The plate can therefore allow a softtissue to have a greater total number of points having suture coupledthereto, e.g., passed therethrough, than a total number of bone fixationelements coupled to, e.g., advanced into, the bone, which can helpreduce damage to the bone and/or help facilitate load balancing. Inother words, a total number of sutures coupled to the soft tissue can begreater than a total number of bone fixation elements coupled to theplate.

The plate can be configured to move between a first configuration inwhich the plate has a first maximum length and a second configuration inwhich the plate has a second maximum length that is greater than thefirst maximum length. For non-limiting example, the plate can beconfigured to be folded in the first configuration and unfolded in thesecond configuration. The plate can be configured to be advanced into apatient's body in the first configuration and to move to the secondconfiguration when at least partially disposed within the patient'sbody, which can allow the plate to be advanced into the patient's bodythrough a relatively small access opening, e.g., incision, therebyreducing patient healing time, improving cosmesis, reducing patienttissue trauma, and/or achieving other benefits of minimally invasivesurgery that will be appreciated by a person skilled in the art. Also bybeing configured to be introduced into a patient's body in a smallersize than when the plate is implanted within the patient, e.g., thesmaller first configuration versus the larger second configuration, theplate can achieve benefit(s) of a minimally invasive surgical procedurewhile allowing a larger surface area of the plate to contact tissue andbone within the patient, which can facilitate healing, than would bepossible with a plate that cannot move to a larger size for implantationwithin a patient's body.

The tissue repair suture plates disclosed herein can be formed in anyway, e.g., molded or woven, from any one or more materials, such as abiocompatible material(s) safe for use in a patient's body. In oneembodiment, the tissue repair suture plate can be formed, e.g., molded,from a biocompatible polymer. A variety of biocompatible polymers can beused to form the biocompatible tissue repair suture plates, such aspolyetheretherketone (PEEK), polylactic acid (PLA), and Biocryl® Rapideavailable from DePuy Mitek of Raynham, Mass. The biocompatible polymerscan be synthetic polymers, natural polymers or combinations thereof. Asused herein the term “synthetic polymer” refers to polymers that are notfound in nature, even if the polymers are made from naturally occurringbiomaterials. The term “natural polymer” refers to polymers that arenaturally occurring.

In an exemplary embodiment, the plates can be formed from and/or coatedwith one or more osteoconductive and/or bioabsorbable materials,although in some embodiments the plates can be made from one or morenon-bioabsorbable materials. By being formed from a bioabsorbablematerial(s), the plate can be configured to naturally degrade and beabsorbed within a patient's body such that a surgical procedure wouldnot be necessary to remove the plate from the patient's body after softtissue has healed. Being formed from and/or coated with anosteoconductive material(s) can allow the plates to facilitate healing,e.g., by encouraging bone growth. Exemplary bioabsorbable materialsinclude poly-L-lactide (PLLA), poly(lactic-co-glycolic acid) (PLGA),poly-L/D-lactide (PLDLA), polyglyconate, polylactic acid (PLA),polyglycolic acid (PGA), polycaprolactone (PCL), polydioxanone (PDO),and trimethylene carbonate (TMC). Exemplary osteoconductive materialsinclude biphasic calcium phosphate, hydroxyapatite, α-tricalciumphosphate, β-tricalcium phosphate, bioactive glass, calcium phosphate,calcium sulfate, calcium carbonate, xenogeneic and allogeneic bonematerial.

The tissue repair suture plates disclosed herein can be formed from amesh material. In an exemplary embodiment, the mesh material can beflexible. The mesh material can be fluid pervious or impervious, and themesh material can be treated to increase or decrease its frictionalinteraction with tissue, as will be appreciated by a person skilled inthe art. For non-limiting example, the mesh material can be treated toincrease its frictional interaction with soft tissue, therebyfacilitating healing by helping to position the soft tissue in optimalcontact with bone.

The mesh material can include a reinforcing material including anyabsorbable or non-absorbable textile having, for non-limiting example,woven, knitted, warped knitted e.g., lace-like), non-woven, and braidedstructures. In any of the above structures, mechanical properties of themesh material can be altered by changing the density or texture of thematerial, the type of knit or weave of the mesh material, the thicknessof the mesh material, or by embedding particles in the material. Themechanical properties of the mesh material can also be altered bycreating sites within the mesh material where the fibers are physicallybonded with each other or physically bonded with another agent, such as,for example, an adhesive or a polymer. The fibers used to make thereinforcing component can be, e.g., monofilaments, yarns, threads,braids, or bundles of fibers. These fibers can be made of any one ormore biocompatible materials, as will be appreciated by a person skilledin the art.

As mentioned above, the tissue repair suture plates can be formed fromone or more non-bioabsorbable materials. Exemplary embodiments ofnon-bioabsorbable materials include biocompatible metals such asstainless steel, cobalt chrome, titanium and titanium alloys, andbioinert ceramic particles (e.g., alumina, zirconia, and calcium sulfateparticles). Other exemplary embodiments of non-bioabsorbable materialsinclude polymers such as polyethylene, polyvinylacetate,polymethylmethacrylate, polypropylene, poly(ethylene terephthalate),silicone, polyethylene oxide, polyethylene glycol, polyurethanes,polyvinyl alcohol, natural polymers (e.g., cellulose particles, chitin,and keratin), and fluorinated polymers and copolymers (e.g.,polyvinylidene fluoride, polytetrafluoroethylene, andhexafluoropropylene).

FIGS. 1-4 illustrate one exemplary embodiment of a surgical plate 10configured to aid in securing a tissue to bone by allowing at least onesuture to be coupled to the tissue without requiring the at least onesuture to be secured to a bone fixation element, e.g., a suture anchor,inserted into the bone. The plate 10 can have a variety of sizes,shapes, and configurations. As shown in the illustrated embodiment, theplate 10 can be an elongate plate having one or more openings 12, alsoreferred to herein as “bores,” formed therethrough that can each beconfigured to seat a bone fixation element, e.g., an anchor 82, therein.The one or more bone fixation elements can be configured to attach theplate 10 to bone. The plate 10 can also include a plurality ofadditional openings 14 each configured to have one or more sutures 86passed therethrough. The plate 10 can also include one or more landregions 18 positioned between adjacent ones of the additional openings14 that can be configured to facilitate coupling the one or more sutures86 to the plate 10, which can facilitate securing a tissue to the plate10. The plate 10 can optionally include one or more hinges 16 that, asdiscussed in more detail below, can be configured to allow the plate 10to be movable between folded and elongated configurations.

In the illustrated embodiment, the plate 10 is substantially rigid,e.g., formed from one or more substantially rigid materials. In otherembodiments, as mentioned above, a plate can be substantially flexible,e.g., formed from one or more substantially flexible materials, suchthat the plate can be deformable. A flexible, deformable plate canfacilitate movement of the plate between folded and expandedconfigurations, as discussed further below, and can help the platedynamically conform to a shape of a bone surface to which the plate isadjacently implanted and dynamically conform to a tissue surface, asalso discussed further below.

The plate 10 is elongate and has a substantially rectangular shape inthe illustrated embodiment, but the plate can be elongate and haveanother shape, e.g., square, oval, dogbone-shaped, irregularly-shaped,etc. The plate 10 can have a tissue seating surface 20 and a bonecontacting surface 22 on an opposite side of the plate 10 from thetissue seating surface 20, e.g., the tissue seating surface 20 being ona top of the plate 10 and the bone contacting surface 22 being on abottom of the plate 10. The tissue seating surface 20 and the bonecontacting surface 22 can each be substantially flat, as in theillustrated embodiment, although the tissue seating surface 20 and/orthe bone contacting surface 22 can have non-flat profiles. Fornon-limiting example, a plate can have a curved or other non-flat bonecontacting surface, which can help the plate approximate a curved shapeof a bone surface at a tissue reattachment site. If a plate issubstantially flexible, the plate can be configured to dynamicallyconform to a curved or other non-flat shape of a bone surface, but if aplate is substantially rigid, having a non-flat bone contacting surfacecan help maximize contact with the bone, which can facilitate healing,e.g., by increased surface area of tissue in contact with bone and/or bypromoting bone growth into the plate caused in part by minimizing voidspace between a bone surface and the bone conforming surface. Similarly,a substantially flexible plate can be configured to dynamically conformto a curved or other non-flat shape of a tissue, but if a plate issubstantially rigid, having a non-flat tissue seating surface can helpmaximize contact with the tissue, which can facilitate healing.

The plate 10 can have a variety of dimensions. In an exemplaryembodiment, the plate 10 can have a substantially non-varying thicknessT. The thickness T of the plate 10 can be different depending on theplate's application and materials of construction. The thickness T canbe in a range of about 1 mm to 2 mm, which can allow the plate'sthickness T to approximate a thickness of a bone cortex. In anotherembodiment, the thickness T can be less than about 0.5 mm, which canfacilitate positioning the plate 10 sub-flush in bone. Generally, thelarger the plate's thickness T, the greater the strength of sutureattachment to the plate 10, also depending on a strength of thematerial(s) forming the plate 10. In some embodiments, a plate can havea thickness that varies along a length of the plate and/or along a widthof the plate. For non-limiting example, a bone contacting surface of theplate can have a shape that a the shape of a bone surface, e.g., becurved, while a tissue seating surface of the plate can be substantiallyflat such that the thickness of the plate varies along the lengththereof in accordance with the bone contacting surface's shape. Theplate 10 can have any length L and any width W. In an exemplaryembodiment, the length L of the plate 10 can be less than about 20 mm,e.g., in a range of about 10 mm to 20 mm, e.g., about 18 mm, etc., andthe width W can be less than about 10 mm, e.g., about 5.5 mm, in a rangeof about 6 mm to 7 mm, etc. The width W in the illustrated embodiment isnon-varying along the length L of the plate 10, but the width W can varyin different portions along the length L, e.g., when the plate has anon-rectangular or non-square shape, such as ovular or dogbone-shaped.

The openings 12 formed in the plate 10 can each have a variety of sizes,shapes, and configurations. The plate 10 can include any number ofopenings 12. In the exemplary embodiment illustrated in FIGS. 1-4, theplate 10 includes two openings 12. The openings 12 can be located atopposed ends of the plate 10 along the length L thereof, which canfacilitate load balancing and help maximize contact of the plate 10 withbone and tissue. The openings 12 can be longitudinally aligned with oneanother along the length L of the plate 10, which can help improve loadbalancing. The openings 12 can also be centered lengthwise and/orwidthwise in the plate 10, which can facilitate load balancing and/orcan help prevent the plate 10 from buckling when anchor(s) are insertedtherethrough. If a plate includes more than two openings, each pair ofopenings formed through the plate can be longitudinally aligned with oneanother. If a plate includes a single opening, the opening can becentered both lengthwise and widthwise along the plate, which canfacilitate load balancing, although the single opening can be offsetlengthwise and/or widthwise.

The openings 12 can each have any size and shape, the same or differentfrom one another. In an exemplary embodiment, the openings 12 can have asame size and shape so that they can interchangeably seat identical bonefixation elements such as the identical anchors 82, shown in FIGS. 3 and4. As shown generally in FIGS. 3 and 4, a system 80 can include theplate 10 and one or more anchors 82. Generally, the size and shape ofthe openings 12 can approximate a size and shape of an outer diameter ofthe anchors 82. The openings 12 can each be sized and shaped such thatan anchor head 84 of the anchor 82 can engage the plate 10 while beingat least partially recessed within the plate 10. In an exemplaryembodiment, the openings 12 can each be sized and shaped such that whenthe anchor 82 is fully seated within the opening 12, e.g., fullydistally advanced therethrough, the anchor head 84 of the anchor 82 canbe seated flush or sub-flush with the tissue seating surface 20 of theplate 10, which can help prevent the anchor head 84 from digging into orotherwise damaging tissue abutting the tissue seating surface 20. Theopenings 12 can each be sized, shaped, and/or include a locking featureconfigured to secure the anchor 82 therein, such as by creating africtional fit, interference fit, compression fit, snap fit, etc.between the anchor head 84 and the plate 10. In this way, once the plate10 is positioned and the anchors 82 are driven into bone, the anchors 82can be locked in place relative to the plate 10, which can help preventinadvertent backing-out of the anchors 82 and/or inadvertent looseningof the plate 10. Additionally or alternatively, a shank 83 of each ofthe anchors 82 can include one or more bone engaging features 87, e.g.,threads (as in the illustrated embodiment), ridges, barbs, texturedgripping surface, etc., which can help prevent inadvertent backing-outof the anchor 82 from bone, as will be appreciated by a person skilledin the art. FIG. 4 illustrates the anchors 82 seated in openings 12 withthe heads 84 flush with the tissue seating surface 20 of the plate 10,with the shanks 83 extending distally beyond the bone contacting surface22 of the plate 10, and with sutures 86 a coupled thereto, e.g., bybeing passed around a suture engaging member located within an innerlumen thereof. Although only one suture 86 a is shown coupled to each ofthe anchors 82, and each of the sutures 86 a is shown as a non-foldedsingle strand, any number of sutures can be coupled to each of theanchors 82, same or different from one another, and any of the suturescan be folded so as to be 2-ply, 3-ply, etc. Also, although anchors 82are shown advanced through each of the openings 12, in use, anchors neednot be advanced through each of the openings 12 and into bone. Fornon-limiting example, a plate can include a plurality of openings ateach opposed end of the plate, with anchor(s) being advanced throughselected ones of the anchor seating openings based on, e.g., patientanatomy.

The openings 12 can each include a shelf 24 configured to facilitateseating an anchor head 84 of the anchor 82 therein. As best shown inFIGS. 2 and 3, the shelves 24 can each have a size and shape that allowsthe anchor head 84 to be seated therein. While the shelves 24 in theillustrated embodiment have a square edge, the shelves 24 can have acontinuous angled edge or a curved edge. The shelf 24 of each opening 12can define differently sized proximal and distal portions of theopening. The proximal portion can have a larger size than the distalportion, which can mimic the anchor head 84 which includes a shelf 85defining proximal and distal portions of the head 84 in which theproximal portion of the head 84 has a larger size than the head's distalportion. The openings need not include shelves, e.g., if anchors to beseated therein have rounded heads, such as with polyaxial anchors.

The anchors 84 shown in FIGS. 3 and 4 are non-limiting embodiments ofanchors that can be used with the plate 10. Any anchor can be receivedin bores formed in any of the plates disclosed herein, such as, fornon-limiting example, HEALIX® available from DePuy Mitek of Raynham,Mass., HEALIX PEEK® available from DePuy Mitek of Raynham, Mass., HEALIXBR® available from DePuy Mitek of Raynham, Mass., and embodiments ofanchors discussed in U.S. Pat. No. 8,114,128 issued Feb. 14, 2012entitled “Cannulated Suture Anchor” and U.S. patent application Ser. No.11/855,670 (U.S. Pat. Pub. No. 2009/0076544) filed Sep. 14, 2007entitled “Dual Thread Cannulated Suture Anchor,” which are herebyincorporated by reference in their entireties.

Although the plate 10 is illustrated in FIG. 4 as having the anchors 82coupled thereto, as mentioned above, one or more bone fixation elementsin addition to or instead of anchors can be coupled to the plate 10 aswell as to other embodiments of plates disclosed herein. As alsomentioned above, the one or more bone fixation elements coupled to aplate can be integrally formed therewith or can be independent elementsmateable to the plate such that the plate can include all integral bonefixation elements, can include no integral bone fixation elements, orcan include a combination of integral and independent bone fixationelements. Exemplary embodiments of bone fixation elements include sutureanchors, a suture bushing or eyelet configured to sliding receive asuture or other flexible securing member therethrough, a sutureline-lock or other unidirectional suture passage mechanism, an adhesiveor cement, etc. Non-limiting embodiments of a suture bushing or eyeletare described in further detail in U.S. Pat. No. 5,860,978 issued Jan.19, 1999 entitled “Methods And Apparatus For Preventing Migration OfSutures Through Transosseous Tunnels,” which is hereby incorporated byreference in its entirety.

Referring again to the embodiment shown in FIGS. 1-4, the plurality ofadditional openings 14, also referred to herein as “holes,” formed inthe plate 10 can each have a variety of sizes, shapes, andconfigurations. The plate 10 can include any number of holes 14 equal toor greater than two so as to define at least one land region 18. Becauseone land region can be defined by two holes, a plate can include a totalnumber of land regions equal to one less than a total number of holes.In the exemplary embodiment illustrated in FIGS. 1-4, the plate 10includes four holes 14 and three land regions 18.

The holes 14 can be located anywhere along the length L of the plate 10.As in the illustrated embodiment, the holes 14 can be formed in anintermediate portion of the plate 10 positioned between the openings 12form in the plate 12. In other words, the openings 12 can be formed inend regions of the plate 10, and the holes 14 can be bookended by theopenings 12. By being located between the openings 12, suture(s) passedthrough the holes 14 can be less likely to interfere with insertion ofbone fixation elements such as the anchors 82 through the openings 12and into bone. The holes 14 can be equidistantly spaced from one anotheralong the length L of the plate 10, which can help improve loadbalancing. The holes 14 can be longitudinally aligned with one anotherand with the openings 12, as best shown in FIG. 1. The holes 14 can alsobe centered lengthwise and/or widthwise in the plate 10, which canfacilitate load balancing and/or can help prevent the plate 10 frombuckling when anchor(s) are inserted therethrough. The holes 14 cangenerally be in the form of slots that extend at least partially acrossthe width W of the plate 10. In an exemplary embodiment, the holes 14can extend across a substantial amount of the width W of the plate 10 soas to maximize a length of the land regions 18 across the plate's widthW, which can provide versatility of placement in passing suture(s) 86through the holes 14 and looping the suture(s) 86 around the landregions 18, as shown in FIG. 4 and discussed further below, and whichcan help maximize a surface area of tissue, e.g., tissue abutting orfacing the plate's tissue contacting surface 20, contacting boneabutting or facing the plate's bone contacting surface 22, which canfacilitate healing.

The holes 14 can each have any size and shape, the same or differentfrom one another. The holes 14 can each have a relatively large sizerelative to a size of the plate 10, which similar to that mentionedabove, can help maximize the surface area of tissue contacting bone. Asin the illustrated embodiment, the holes 14 immediately adjacent to theopenings 12, e.g., outermost ones of the holes 14, can have a differentshape than the other holes 14. This different shape can reflect theshape of the openings 12 so as to help maximize the size of the holes 14while providing an adequate thickness between the openings 12 and theholes 14 to help maintain structural integrity of the plate 10.

As mentioned above, the land regions 18 can be located between adjacentones of the holes 14 and can each be configured to engage one or moresutures 86, also referred to herein as “strands of suture” or “suturestrands,” passed through the adjacent holes 14 defining the land region18. In other words, the land regions 18 can be configured as sutureengaging members configured to receive at least one suture 86therearound such that limbs or trailing ends of the suture(s) 86 canextend through different one of the holes 14. The land regions 18 cantherefore provide a surface for one or more of the suture strands 86 toabut against, which can facilitate pulling tissue coupled to thesuture(s) into contact with the plate 10.

The land regions 18 can have a variety of sizes, shapes, andconfigurations, the same or different from one another. The land regions18 in the embodiment shown in FIGS. 1-4 are identical to one another. Asin the illustrated embodiment, the land regions 18 can include generallyelongate bars or rods having a substantially uniform, oval crosssectional shape, although the cross sectional shape of the land regions18 can vary along lengths thereof. For non-limiting example, portions ofthe land regions 18 can have one or more suture-abutting regions thatcan have a curved or circular cross sectional shape, and one or morenon-suture abutting regions that can have a different cross sectionalshape, e.g., a rectangular shape. In addition, the suture-abuttingportions can be recessed in the land regions 18 to help maintaindifferent suture strands at different locations along the length of theland regions 18. The ovular cross sectional shape of the land regions 18can provide a relatively smooth surface for the suture strands 86 toabut against, which can reduce the likelihood of the sutures 86 frayingas they abut and/or are slid against the land regions 18. In anotherembodiment, the cross sectional shape of the land regions 18 can benon-oval, e.g., a semicircular or crescent-shaped where a bottom ordistal portion of the land region can be curved while a top portion canbe flat, rectangular, triangular, irregularly shaped, etc.

One or more sutures 86 can be slidably disposed around land regions 18by being passed through adjacent openings 14. The suture(s) 86 can eachbe coupled to tissue (not shown) to help secure the tissue to the plate10 and to bone underlying the plate 10. The suture(s) 86 can thereforeallow the tissue to be secured to the bone without an anchor or otherfixation element connected to the suture(s) 86 being inserted into thebone, which can help prevent damaging the bone, as mentioned herein.While only one suture 86 is shown coupled to each land region 18, anynumber of sutures 86 can be coupled to each land region 18, the same ordifferent from one another. Although each of the sutures 86 is shown asa non-folded single strand, any of the sutures can be folded so as to be2-ply, 3-ply, etc. The sutures 86 can each be coupled to a single landregion 18, as shown in FIGS. 3 and 4, or any of the sutures 86 can makemore than two passes through the holes 14, e.g., to weave sutures 86through more than two of the holes 14 to create additional frictionalengagement with the land regions 18. The sutures 86 can slidably engagethe land regions 18, as also shown in FIGS. 3 and 4, such that thesutures 86 can freely slide therearound, at least until a tissue iscoupled to the sutures 86 and the plate 10 is attached to bone.Alternatively, any of the sutures 86 can be tied or knotted to any ofthe land regions 18, which can help prevent tissue movement relative tothe plate 10 and underlying bone when the plate 10 is attached to thebone. Although each of the land regions 18 has a suture 86 coupledthereto in the illustrated embodiment, one or more of the land regions18 may not have a suture coupled thereto based on, e.g., a size of atissue coupled to the plate 10.

In an exemplary embodiment, each of the sutures 86 coupled to the landregions 18 can be preloaded, e.g., coupled to the plate 10 before theplate 10 is introduced into a patient's body. The sutures 86 can bepreloaded by a surgeon or other user associated with a surgicalprocedure in which the plate 10 is to be used, or the plate 10 can beprovided as a sold unit to surgeon or other user associated with asurgical procedure with the sutures 86 already coupled thereto.Providing the plate 10 with the sutures 86 coupled thereto as a soldunit can help save surgical time.

As mentioned above and as shown in FIG. 4, in addition to coupling theone or more sutures 86 to the land regions 18, one or more sutures 86 acan also be coupled to one or more of the anchors 82 (or other bonefixation elements) seated in the openings 12, which can provideadditional tissue fixation points for tissue coupled to the sutures 86and help distribute the load along the tissue when the plate 10, andhence the tissue coupled thereto, is secured against bone.

The plate 10 can, as mentioned above, optionally be configured to bemovable between folded and expanded configurations. Being so movable canfacilitate introduction of the plate 10 into a patient's body through atissue opening having diameter that is less than the length L of theplate 10, e.g., less than an implanted size of the plate 10. The plate10 can be biased to the expanded configuration such that an externalforce is required to maintain the plate 10 in the folded configuration,which can help prevent the plate 10 from folding after implantation in apatient's body and consequently moving tissue out of contact withunderlying bone. In embodiments where a plate is substantially flexible,e.g., when the plate is formed from a flexible material such as a meshmaterial, the plate in the folded configuration can be folded any numberof times along any number of portions thereof. A flexible plate can,however, include one or more predetermined folding regions, which canfacilitate folding of the plate in predictable area(s) that may be lesslikely to cause any damage to the plate and/or interfere with anysutures coupled thereto. In embodiments where a plate is substantiallyrigid, the plate can have one or more predetermined folding regions,same or different from one another, configured to allow folding of theplate. The predetermined folding regions can have a variety ofconfigurations. Non-limiting examples of a predetermined folding regionincludes a weakened region of the plate, a scored region of the plate, aregion of the plate formed from a flexible material, and a hinge, e.g.,a living hinge.

As mentioned above, the plate 10 shown in FIGS. 1-4 includes a hinge 16,which can be configured as a predetermined folding region at which theplate 10 can be folded to thereby be in a folded configuration. Theplate 10 is shown in an expanded configuration in FIGS. 1-4, with thelength L of the plate 10 defining a maximum length of the plate 10 inthe expanded configuration and with the width W of the plate 10 defininga maximum width of the plate 10 in the expanded configuration. When theplate 10 is in the folded configuration, the plate's maximum lengthand/or maximum width can be respectively less than the maximum lengthand/or maximum width of the plate 10 in the expanded configuration,which can facilitate introduction of the plate 10 into a body of apatient through a relatively small tissue opening.

The hinge 16 can be located anywhere along the length L of the plate 10,such as in the intermediate region of the plate 10 between the openings12. The plate 10 can therefore be folded at a location between theopenings 12. The hinge 16 can be located in the intermediate regionimmediately adjacent to a one of the openings 12 such that all of theholes 14 are located on one side of the hinge 16, which can minimize asize of plate 10 in the folded configuration and facilitate minimallyinvasive introduction of the plate 10 into a patient's body.

The hinge 16 can have a variety of sizes, shapes, and configurations. Inan exemplary embodiment, the hinge 16 can include a living hinge, e.g.,a thinned region of the plate 10 formed from a same material(s) as aremainder of the plate 10. The hinge 16 as a living hinge, as in theembodiment illustrated in FIGS. 1-4, can ease manufacturing the plate10, such as by injection molding. The hinge 16 can have any number ofother configurations, as will be appreciated by a person skilled in theart, such as a barrel hinge. The hinge 16 can extend lengthwise (e.g.,substantially parallel to a longitudinal axis of the plate 10),widthwise (e.g., substantially perpendicular to the longitudinal axis ofthe plate 10), or at another angle along the plate 10 (e.g.,intersecting the longitudinal axis of the plate 10 at a non-zero andnon-90-degree angle). The hinge 16 can extend widthwise along the entirewidth W of the plate 10, as in the illustrated embodiment. Although theplate 10 only includes one hinge 16, the plate 10 can include at leastone additional hinge, such an additional hinge adjacent the opening 12at the end of the plate 10 opposed to the end that includes theillustrated hinge 16.

As mentioned above, the plate 10 shown in FIGS. 1-4 has a constant widthW along the length L of the plate 10, but a plate can have a non-varyingwidth along a length thereof. In an exemplary embodiment, a plate havinga non-varying width can be wider at opposed ends thereof than in anintermediate portion of the plate extending between the opposed ends.The plate can therefore be configured to be coupled to bone fixationelement(s) at at least one of the opposed ends thereof, either bycoupling to independent bone fixation element(s) or having bone fixationelement(s) integrally formed therewith, while minimizing an amount ofthe plate between the opposed ends thereof that contact underlying boneso as to maximize an amount of tissue coupled to the plate in contactwith the bone, which can facilitate healing.

FIG. 5 illustrates an embodiment of a plate 30 having a non-varyingwidth along a length L2 thereof. The plate 30 can generally beconfigured and used similar to other plates disclosed herein withlike-named elements, e.g., openings 32, holes 34, land regions 38, and ahinge 36, configured and used similar to others discussed herein. Theholes 34 in this illustrated embodiment each have substantially circularshapes and are arranged in the plate 10 in pairs, e.g., three pairs oftwo holes. The plate 30 of FIG. 5 has a dogbone shape such that theplate 10 has a varying width along the length L2 thereof. A plate canhave a varying width along a length thereof while having another shape,such as an ovular shape or an hourglass shape. As mentioned above,having a varying width can help minimize a surface area of the plate 30in contact with bone underlying the plate 10 and maximize a surface areaof tissue coupled to the plate 10 in contact with the bone. In theillustrated embodiment, the plate 30 has a first width W2 at opposedends 40 thereof in which the openings 32 are formed through the plate30, and the plate 30 has a second, smaller width W3 in an intermediateportion of the plate 30 extending between the opposed ends 40. The firstwidth W2 can be the same at both of the opposed ends 40. The secondwidth W3 can be substantially constant as in the illustrated embodiment.In the illustrated embodiment the second width W3 of the intermediateportion is approximately half the first width W2 of the opposed ends 40,but the first and second widths W2, W3 can have any ratio, and, asmentioned above, the first and second width W2, W3 can be different fromeach other in different parts of the plate 10.

While a single intermediate portion is shown in the embodiments of FIGS.1-5, in another embodiment, a plate can include multiple, narrowerintermediate portions, and each intermediate portion can have at leastone hole formed therethrough. For example, a plurality of intermediateportions can be disposed substantially parallel to one another betweenopposed ends of the plate. In addition, or instead of, holes formedthrough the intermediate region of the plate, additional land regionscan extend transverse to the multiple intermediate regions resulting ina grid of land regions where one or more suture strands can be coupled.In general, increasing the number of locations where suture strands canbe coupled to the surface of the plate can provide greater flexibilityof suture placement and/or tissue tensioning during surgery and canallows greater distribution of load along the tissue.

A plate can optionally include one or more bone engaging surfacefeatures configured to engage bone underlying a bone contacting surfaceof the plate. The one or more bone engaging surface features canfacilitate secure attachment of the plate to the bone, can help minimizemovement of the plate relative to the bone after implantation within apatient's body, and/or can help stabilize the plate relative to the boneprior to anchor(s) coupled to the plate being fully inserted into thebone. The bone engaging surface features can have a variety of sizes,shapes, and configurations. Generally, the bone engaging surfacefeatures can be formed on and/or extend away from the plate's bonecontacting surface. Non-limiting examples of bone engaging surfacefeatures include a protrusion, a textured surface, a pin, and a tackysurface. A plate can include any number of bone engaging surfacefeatures and can include the bone engaging surface features at anylocation(s) along the plate. Bone engaging surface features can beintegrally formed with the plate, such as by molding the bone engagingfeatures with the plate, or the bone engaging surface features can beaffixed to the plate in any number of ways, such as interference fit,snap fit, welded, adhered with glue and/or other adhesive, etc.

FIG. 6 illustrates an embodiment of a plate 50 that includes one or morebone engaging surface features 60 extending from a bone contactingsurface 62 of the plate 50. The plate 50 can generally be configured andused similar to other plates disclosed herein with like-named elements,e.g., openings 52, holes 54, land regions 58, and a hinge 56, configuredand used similar to others discussed herein. The plate 50 includes fourbone engaging surface features 60, but as mentioned above, the plate 60can include any number of bone engaging surface features 60. In anexemplary embodiment, the bone engaging surface features 60 can bepositioned adjacent the openings 52, which can help prevent the boneengaging surface features 60 from interfering with suture(s) (not shown)passed through any of the holes 54. In the illustrated embodiment, boneengaging features 60 are in the form of sharp, pointed protrusionsextending from a bone contacting surface 62 of the plate that areconfigured to penetrate into bone.

A plate can be configured to be mated to one or more bone fixationelements, such as with the plates illustrated in FIGS. 1-5. In otherwords, the plate and the one or more bone fixation elements can beindependent elements. A plate can, however, be integrally formed withone or more bone fixation elements such that the bone fixationelement(s) need not be independently mated to the plate. A plate withintegral bone fixation elements can help save time during a surgicalprocedure because independent bone fixation element(s) need not bealigned with plate openings and advanced therethrough into bone andbecause each independent bone fixation element need not be advancedseparately, e.g., sequentially, into bone. A plate with integral bonefixation elements can generally be easier to implant in an open surgicalprocedure than in a minimally invasive surgical procedure because theplate's bone fixation element can be more easily all advanced into boneat once. If a plate is configured to seat independent bone fixationelements, the plate can be provided as part of a kit including one ormore bone fixation elements configured to be seated in openings of theplate. The kit can also include one or more additional plates configuredto seat one or more of the bone fixation elements included in the kit.Each of the plates included in a kit can be different from one anotherin one or more ways, e.g., in size, in shape, in flexibility, etc. Eachof the bone fixation elements included in a kit can be identical to oneanother, or any one or more of the bone fixation elements can vary fromother bone fixation elements included in the kit in any one or more waysA plate and bone fixation element(s) can be selected as appropriate fromthe kit for use in a particular surgical procedure based on, e.g.,patient anatomy, type of tissue being attached to bone, etc.

FIG. 7 illustrates an embodiment of a plate 70 that does not includeopenings but that does include one or more bone fixation elements in theform of anchors 72 integrally coupled thereto such that the plate 70 andthe anchors 72 form a unitary element. The plate 70 can generally beconfigured and used similar to other plates disclosed herein withlike-named elements, e.g., holes 75, suture 76, land regions 77, and ahinge 74, configured and used similar to others discussed herein. Theplate 70 includes four integral anchors 72 coupled thereto, but a platecan include any number of integral bone fixation elements coupledthereto. In an exemplary embodiment, the integral anchors 72 can bepositioned similar to the positioning discussed above regarding aplate's openings, such as adjacent opposed ends of the plate 70. In theillustrated embodiment, each of the integral anchors 72 is in the formof a sharp, pointed protrusion extending from a bone contacting surface78 of the plate 70 and having a plurality of bone engaging features inthe form of ridges. The integral anchors 72 can be integrally formedwith the plate 70 in any number of ways, such as by molding the anchors72 with the plate 70, welding thereto, snap fit, compression fit,adhered with glue and/or other adhesive, etc.

The plates discussed herein can be used in attaching tissue to bone in avariety of surgical procedures, such as a procedure for attaching tissueto bone, e.g., anterior cruciate ligament (ACL) repair, rotator cuffrepair, etc. In an exemplary embodiment, a procedure includingimplantation of the plate can be a minimally invasive procedure, but aswill be appreciated by a person skilled in the art, the plates discussedherein also have application in open surgical instrumentation as well asapplication in robotic-assisted surgery.

FIGS. 8-11 illustrate an exemplary embodiment of securing soft tissue tobone including implanting a plate adjacent bone to allow a soft tissuecoupled to the plate via one or more sutures to contact the bone toattach the tissue thereto. While FIGS. 8-11 show securing soft tissue tobone in a rotator cuff repair, the methods and devices disclosed hereincan be used at a variety of anatomical locations and in a variety ofmedical procedures in which tissue is attached to bone, as mentionedabove. Additionally, although FIGS. 8-11 are discussed with reference tothe plate 30 of FIG. 5 and the anchor 82 of FIGS. 3 and 4, any of platesand any of the bone fixation elements discussed herein can be implantedin this or other ways.

The surgical procedure can include preparing the patient for surgeryusing standard techniques. In a minimally invasive procedure, one ormore introducer devices (not shown), e.g., a cannula, a trocar, etc.,can be advanced through an opening in the patient to provide access to asurgical site. The plate 30 can be introduced into a patient throughsuch an introducer device, or advanced directly into the patient. Aperson skilled in the art will appreciate that one or more viewingdevices, e.g., a scoping device such as an endoscope, can be advancedinto the body through the incision or through another opening, e.g.,another incision or a natural orifice, to provide visualization of thesurgical site from outside the body. Although a cannula can bepositioned in an incision and the plate 30 and a delivery device 94configured to deliver the plate 30 to a surgical site can be insertedtherethrough, for clarity, FIGS. 8 and 10 show the delivery device 94without an introducer device therearound.

The delivery device 94 can have a variety of sizes, shapes, andconfigurations. Although the delivery device 94 is shown in FIGS. 8 and10 as delivering the plate 30 to the surgical site, any number of otherdelivery devices can be used to deliver the plate 30 to the surgicalsite. As in the illustrated embodiment, the delivery device 94 caninclude a shaft 96 having a handle portion 98 at a proximal end thereofthe shaft 96 and a mating portion (obscured in FIGS. 8 and 10) at adistal end of the shaft 96 configured to mate to a proximal end of ananchor, such as the anchor 82 or an anchor integrally formed with aplate. The delivery device 94 can include at least one suture engagingfeature 100 configured to engage one or more sutures, e.g., the sutures86 pre-fed through the holes 34 formed through the plate 30. The atleast one suture engaging feature 100 can be located anywhere on thedelivery device 94, but in an exemplary embodiment, the at least onesuture engaging feature 100 can be located in a proximal portionthereof, e.g., at the proximal end of the shaft 96, which can allow thesutures engaging the at least one suture engaging feature 100 to extendoutside the patient's body for manipulation, as the shaft's proximal endcan remain outside the patient's body throughout the surgical procedure.The at least one suture engaging feature 100 can have a variety ofsizes, shapes, and configurations, such as an eyehole (as in theillustrated embodiment), a clamp, a clip, a groove formed in thedelivery device 94, a spool, etc. The eyehole's opening in theillustrated embodiment is circular and is substantially perpendicular toa longitudinal axis of the shaft 96 of the delivery device 94, but aneyehole's opening can have any shape and can be at any orientationrelative to the shaft's longitudinal axis.

FIG. 12 illustrates another embodiment of a delivery device 104 thatincludes a suture engaging feature 106 in the form of an o-ringextending around an external perimeter of a handle 130 of the deliverydevice 104. FIG. 12 also shows a distal end of the delivery device 104coupled to an anchor 108 mated to a plate 114 and shows a plurality ofsutures 112 coupled to the suture engaging feature 106, extendinglongitudinally along the delivery device 104, and coupled to the plate114. The plate 114 can be generally configured and used similar to otherplates disclosed herein.

Referring again to the embodiment of FIGS. 8-11, prior to delivery ofthe plate 30, a bone surface 90 of a bone 91 to which the plate 30 is tobe attached can be prepared, as will be appreciated by a person skilledin the art. For non-limiting example, one or more bores 102 can beformed in the bone surface 90 to respectively receive the anchors 82therein, and the bone surface 90 where the plate 30 is to be affixed canbe decorticated prior to affixing the plate 30 thereto, which can helpposition the plate 30 flush with the bone surface 90. The bore 102 canbe sized to fully receive the anchor 82 therein, or the bore 102 can bea starter bore that is smaller than the anchor 82, with the anchor 82being configured to penetrate into bone as necessary to fit the anchor82 therein. A diameter of the bore 102 can be slightly less than amaximum outer diameter of the anchor 82, and a length of the bore 102can be substantially equal to or greater than a length of the anchor 82.The bore 102 can extend fully through cortical bone to allow the anchor82 to be fully engaged through the thickness of the cortical bone. Asingle bore 102 is shown as being initially formed in FIG. 8, butmultiple initial bores 102 can be formed, e.g., for each of the anchors82 already coupled or to be coupled to the plate 30, prior to any of theanchors 82 being advanced into the bone 91. In an exemplary embodiment,the bores 102 can be first formed for anchor(s) at one opposed end ofthe plate 30 and formed for anchor(s) at one opposed end of the plate 30after the anchor(s) are advanced into the first bore(s) 102 to helpensure that the additional bores 102 properly align with the additionalanchors.

As shown in FIG. 8, the delivery device 84 can deliver the plate 30 in afolded configuration adjacent to the bone surface 90 at a tissueattachment site 92. The plate 30 can be coupled to the distal end of thedelivery device 94 outside the patient's body, and then the distal endof the delivery device 94 with the plate 30 coupled thereto can beadvanced into the patient's body, such as through an introducer deviceas discussed above. The plate 30 can be coupled to the delivery device94 in a variety of ways. In an exemplary embodiment, the anchor 82 canbe advanced into the opening 32 formed through the plate 30, and thedelivery device's distal end can be coupled to the anchor 82, such as bybeing advanced through a proximal end of the anchor 82 and into an innerlumen of the anchor 82. The delivery device's distal end can be coupledto the anchor 82 before or after the anchor 82 is advanced into theopening 32. In an exemplary embodiment, the anchor 82 to which thedelivery device 94 is coupled during delivery of the plate 30 in thefolded configuration to the site 92 is seated in the opening 32 adjacentto the hinge 36, which can minimize the plate's footprint in the foldedconfiguration, which, as mentioned above, can allow the plate 30 to beadvanced into a patient's body through a relatively small opening, suchas an incision.

One or more sutures 88 attached to the plate 30 can engage the sutureengaging feature 100 of the delivery device 94 prior to the plate 30being advanced into the patient's body. The one or more sutures 88 canbe attached to the plate 30 by passing through the holes 34 and engagingthe land regions 38. The sutures 88 can be attached to the plate 30before the delivery device 94 is coupled to the plate 30, such as by thesutures 88 being pre-fed through the holes 34. Although a single strandof suture 88 is passed through each of the holes 34 such that each ofthe holes 34 has one suture 88 extending therethrough and such that eachof the land regions 38 has one suture engaged therewith, as mentionedabove, any number of sutures can be passed through any one or more ofthe holes 34 and can be folded any number of times. Additionally, thesutures 88 in the illustrated embodiment are slidably coupled to theplate 30, but the sutures 88 can be non-slidably coupled thereto, e.g.,by tying the sutures 88 to one or more of the land regions 38 or weavingor making multiple passes through the holes 34 to provide additionalfrictional engagement with the plate 30.

The plate 30 can be coupled to the delivery device 94 in an expandedconfiguration, and the introducer device (not shown), e.g., a cannulatedchannel thereof, can apply an external force to the plate 30 to move theplate 30 from the expanded configuration to the folded configuration,e.g., to bend the plate 30 at the hinge 36, and hold the plate 30 in thefolded configuration during delivery to the tissue attachment site.Additionally or alternatively, a distal pulling force can be applied tosuture(s) 88 coupled to the plate 30 to apply an external force to theplate 30 to move the plate 30 from the expanded configuration to thefolded configuration, and hold the plate 30 in the folded configurationduring delivery to the tissue attachment site, regardless of whether theplate 30 is fully or partially disposed within an introducer device.

Thus, as shown in FIG. 8, the plate 30 can be delivered to the tissueattachment site 92 in the folded configuration with different regions ofa tissue seating surface of the plate 30 moved toward one another, withthe intermediate portion of the plate 30 and one opposed end of theplate 30 (e.g., the opposed end which does not have the anchor 82 seatedtherein to which the delivery device 94 is coupled) extending along thedelivery device's shaft 96, with the anchor 82 positioned within one ofthe openings 32, with the sutures 88 passing through the holes 34 andaround the land regions 38, and with the sutures 88 extending from theplate 30 along the shaft 96 to the suture engaging feature 100. If aplate has more than one hinge, the plate can be bent at any one or moreof the hinges during delivery into a patient's body.

Once the plate 30 and the anchor 82 are positioned at the tissueattachment site 92, the delivery device 94 can drive the anchor 82 atleast partially into the bore 102 (or into the bone 91 directly if thebore 102 is not pre-formed in the bone 91) to affix a first end of theplate 30 to the bone 91. As in the illustrated embodiment, the anchor 82and the opening 32 can be sized to allow relative rotational motiontherebetween so the orientation of the plate 30 is not disrupted whenthe anchor 82 is driven into the bone 91. When the anchor 82 is beingdriven into the bone 91, the other opposed end of the plate 30, e.g.,the end extending along the shaft 96 of the delivery device 94, and/orat least a portion of the plate's intermediate portion can remaindisposed within the introducer device (if used). The plate 30 cantherefore remain in the folded configuration when the anchor 82 isdriven into the bone 91, and the sutures 88 can extend proximally awayfrom the anchor 82, thereby helping to prevent snagging the anchor 82 onany of the sutures 88, which could damage the anchor 82 and/or thesutures 88. Because the anchor 82 can be advanced through the opening32, which can have a diameter larger than a maximum diameter of theanchor 82, the anchor 82 can be driven into the bone 91 withoutdisrupting the orientation of the plate 30 relative to the bone 91 whenthe anchor 82 is driven into the bone 91. In other words, the anchor 82can be rotated to threadably advance into the bone 91 without rotatingthe plate 30.

The anchor 82 can be fully or partially advanced into the bone 91 beforethe anchor 82 at the other opposed end of the plate 30 is driven intothe bone 91 and/or before the plate 30 moves from the foldedconfiguration to the expanded configuration. In an exemplary embodiment,the anchor 82 can be partially driven into the bone 91, and the plate 30can then be rotated and/or otherwise repositioned relative to the anchor82 to optimally positioned the plate 30 relative to the bone 30, e.g.,to align the plate 30 with a decorticated area of the bone 91.

In another embodiment using one or more bone fixation elements otherthan anchors, such as a suture line-lock or a suture bushing or eyelet,a plate can be attached to bone by positioning one or more openingsformed through the plate above respective tunnel(s) prepared through thebone, and passing and securing suture through the opening(s) and thetunnel(s). Non-limiting embodiments of using a suture bushing or eyeletto attach suture to bone are described in further detail inpreviously-mentioned U.S. Pat. No. 5,860,978 issued Jan. 19, 1999entitled “Methods And Apparatus For Preventing Migration Of SuturesThrough Transosseous Tunnels.”

Referring again to the embodiment of FIGS. 8-11, as shown in FIG. 9, atleast one additional suture 88 a can be coupled to the anchor 82. The atleast one additional suture 88 a can be coupled to the anchor 82 beforeor after the anchor 82 is advanced into the bone 91 and before or afterthe plate 30 moves from the folded configuration to the expandedconfiguration. The at least one additional suture 88 a can be coupled tothe suture engaging feature 100 of the delivery device 94 similar tothat discussed above regarding the sutures 88.

As also shown in FIG. 9, after the anchor 82 has been driven into thebone 91, the plate 30 can be moved from the folded configuration to theexpanded configuration, e.g., by bending the plate 30 at the hinge 36 inthe direction A, to position the other opposed end adjacent to the bone91. If the sutures 88 were not coupled to the plate 30 prior to deliveryof the plate 30 to the tissue attachment site 92, the sutures 88 can becoupled to the plate 30 prior to or during movement of the plate 30 tothe expanded configuration. Another anchor 82 can be advanced throughthe other opening 32 formed through the plate 30 and into the bone 91,as shown in FIG. 10. As mentioned above, another bore 102 can be formedat a location where the other anchor 82 will be advanced into the bone91, and the other anchor 82 can be advanced into the other bore 102.Before the other bore 102 is formed, the plate 30 can be unfolded tomove from the folded configuration to the expanded configuration toensure proper alignment between the opening 32 and the other bore 102,e.g., the bore 102 can be formed by drilling through the opening 32. Theother anchor 82 can be advanced into the bone 91 in a variety of ways.In an exemplary embodiment, after the anchor 82 is advanced at leastpartially into the bone 91, the delivery device 94 can be uncoupledtherefrom, e.g., removed from the anchor's inner lumen, and can becoupled to the other anchor 82, by inserting the delivery device'sdistal end into an inner lumen of the other anchor 82. The deliverydevice 94 can then drive the other anchor 82 into the bone 91 similar tothe delivery device's driving on the anchor 82 into the bone 91. Similarto that mentioned above, the other anchor 82 can be advances into thebone 91 without disrupting the orientation of the plate 30 relative tothe bone 91. The sutures 88 can be disengaged from the delivery device94 prior to driving the other anchor 82 into the bone 91, as shown inFIG. 10, which can help prevent the sutures 88 from snagging on theother anchor 88 and/or tangling on the delivery device's shaft 94.Whether engaged with or disengaged from the delivery device 94 prior todriving the other anchor 82 into the bone 91, the sutures 88 and theadditional suture 88 a can be tensioned to keep the sutures 88 and theadditional suture 88 a substantially taught, as shown in FIG. 10, whichcan help prevent the sutures 88 from snagging on the other anchor 88and/or tangling on the delivery device's shaft 94.

At least one additional suture (not shown) can be coupled to the otheranchor 82, similar to the at least one additional suture 88 a discussedabove regarding the anchor 82. The at least one additional suture can becoupled to the other anchor 82 before or after the other anchor 82 isadvanced into the bone 91 and before or after the plate 30 moves fromthe folded configuration to the expanded configuration. The at least oneadditional suture can be coupled to the suture engaging feature 100 ofthe delivery device 94 similar to that discussed above regarding thesutures 88.

After the second anchor 82 is at least partially driven into the bone91, each of the anchors 82 advanced through the plate's openings 32 canbe fully driven into the bone 91, if not already so fully driven, so asto seat the anchors' heads into the anchor seating openings 32. Asdiscussed above, one or both of the openings 32 can include a lockingfeature configured to secure the anchors 82 therein.

After the plate 30 is affixed to the bone 91, the sutures 88 are coupledto the plate 30, and the additional sutures 88 a are coupled to theanchors 82, a tissue 110 can be attached to the plate 30 and the bone 91via the sutures 88, 88 a, as shown in FIG. 11. The tissue 110 can beattached to the sutures 88, 88 a in any order and at any time duringattachment of the tissue 110 to the bone 91. In an exemplary embodiment,the tissue 110 can be attached to each of the sutures 88, 88 a after theplate 30 has been attached to the bone 30 by fully advancing the anchors82 into the bone 91. Each of the sutures 88, 88 a can be passed throughone of a plurality of fixation points 120 in the tissue 110 that caneach be substantially directly above the location where each of thesutures 88, 88 a is coupled to the plate 30 or the anchors 82.

The tissue 110 can be advanced to the bone surface 90 in any number ofways as will be appreciated by a person skilled in the art, such as bypulling and positioning the tissue 110 into proximity of the plate 30until a surface of the tissue 110 abuts a tissue seating surface of theplate 30. Advancing the tissue 110 into contact with the tissue seatingsurface of the plate 30 in a distal direction can facilitate a smoothinterface between a surface of the tissue 110 and the plate 30 and helpavoid pulling the tissue 110 in a transverse direction which can causethe tissue 110 to pucker or fold, which can have an adverse impact onthe integrity of the tissue attachment. After the tissue 110 is pulledinto contact with the tissue seating surface of the plate 30, the tissue110 can be secured to the plate 30 in any way, such as by tying or byknotting. The tissue 110 can thus be secured to the plate 30 and thebone surface 90 at a plurality of fixation points 120 located along thesurface of the tissue 110. The greater a number of fixation points, themore the load on the tissue 110 at any one point can be reduced, therebyincreasing the likelihood that the tissue 110 will successfullyre-attach to the bone 91 in a timely manner and not tear away from anyof the fixation points 120.

The various methods and devices disclosed herein can be used in avariety of surgical procedures, however the methods and devices areparticularly useful for repairing a torn rotator cuff in a humanshoulder.

A person skilled in the art will appreciate that the present inventionhas application in conventional minimally-invasive and open surgicalinstrumentation as well application in robotic-assisted surgery.

The devices disclosed herein can also be designed to be disposed ofafter a single use, or they can be designed to be used multiple times.In either case, however, the device can be reconditioned for reuse afterat least one use. Reconditioning can include any combination of thesteps of disassembly of the device, followed by cleaning or replacementof particular pieces and subsequent reassembly. In particular, thedevice can be disassembled, and any number of the particular pieces orparts of the device can be selectively replaced or removed in anycombination. Upon cleaning and/or replacement of particular parts, thedevice can be reassembled for subsequent use either at a reconditioningfacility, or by a surgical team immediately prior to a surgicalprocedure. Those skilled in the art will appreciate that reconditioningof a device can utilize a variety of techniques for disassembly,cleaning/replacement, and reassembly. Use of such techniques, and theresulting reconditioned device, are all within the scope of the presentapplication.

One skilled in the art will appreciate further features and advantagesof the invention based on the above-described embodiments. Accordingly,the invention is not to be limited by what has been particularly shownand described, except as indicated by the appended claims. Allpublications and references cited herein are expressly incorporatedherein by reference in their entirety.

What is claimed is:
 1. A surgical plate, comprising: an elongate platemember having bone fixation elements coupled to opposed ends of theplate; at least one hinge region formed between the bone fixationelements, the hinge region extending across a width of the plate; aplurality of openings formed through the plate member and extending froma bone contacting surface thereof to a soft tissue seating surfacethereof; and one or more suture strands slidably disposed within theplurality of openings.
 2. The surgical plate of claim 1, wherein theopenings include a plurality of slots formed along a length of theelongate plate member, and the one or more suture strands are slidablydisposed within the plurality of slots.
 3. The surgical plate of claim1, wherein the one or more suture strands extend from the elongate platemember and are configured to secure soft tissue to the tissue seatingsurface of the elongate plate member.
 4. The surgical plate of claim 3,wherein the one or more suture strands are secured through one or moreof the openings, each strand having a portion abutting a land region ofthe elongate plate member located between adjacent openings, having afirst suture limb extending from a first one of the adjacent openings,and having a second suture limb extending from a second one of theadjacent openings.
 5. The surgical plate of claim 1, wherein theelongate plate member is bioabsorbable and is made from a materialselected from the group consisting of poly-L-lactide (PLLA),poly(lactic-co-glycolic acid) (PLGA), poly-L/D-lactide (PLDLA),polyglyconate, polylactic acid (PLA), polyglycolic acid (PGA),polycaprolactone (PCL), polydioxanone (PDO), and trimethylene carbonate(TMC).
 6. The surgical plate of claim 1, wherein the elongate platemember is osteoconductive and is at least one of made from and coatedwith a material selected from the group consisting of biphasic calciumphosphate, hydroxyapatite, α-tricalcium phosphate, β-tricalciumphosphate, bioactive glass, calcium phosphate, calcium sulfate, calciumcarbonate, xenogeneic and allogeneic bone material.
 7. The surgicalplate of claim 1, wherein the elongate plate member has an intermediateportion between the opposed ends, and the width of the plate at theopposed ends is greater than the width of the plate at the intermediateportion.
 8. The surgical plate of claim 1, further comprising bonefixation elements configured to be seated in bores formed in the opposedends of the plate so as to couple the bone fixation elements to a bone,the bone fixation elements being configured to be fixated to the bone.9. The surgical plate of claim 1, wherein the bone fixation elementscomprise one or more of a suture, a suture bushing, and an anchor. 10.The surgical plate of claim 1, wherein the bone fixation elements areintegrally formed with the plate.
 11. A soft tissue anchoring system,comprising: one or more anchors having a head and at least one boneengaging surface feature on a shank thereof; an elongate plate memberhaving one or more bores formed therein for receiving the one or moreanchors, and a plurality of openings extending therethrough and formedalong a length of the elongate plate member; a plurality of suturestrands extending from the plate member and slidably disposed within theopenings; and at least one hinge on the elongate plate member.
 12. Asurgical plate, comprising: an elongate plate member having bonefixation elements coupled to opposed ends of the plate; at least onehinge region formed between the bone fixation elements, the hinge regionextending across a width of the plate; a plurality of openings formedthrough the plate member and extending from a bone contacting surfacethereof to a soft tissue seating surface thereof; and a plurality ofsuture strands secured through one or more of the openings, each suturestrand having a first suture limb extending from a first one of theopenings and having a second suture limb extending from a second one ofthe openings adjacent to the first one of the openings.
 13. The surgicalplate of claim 12, wherein the plurality of suture strands extend fromthe elongate plate member and are configured to secure soft tissue tothe tissue seating surface of the elongate plate member, each suturestrand having a portion abutting a land region of the elongate platemember located between adjacent openings.